古矢 丈雄

We report a surgically-treated case of a thoracic dumbbell-shaped spinal tumor with contralateral buttock and lower extremity pain. A 72-year-old man was admitted with buttock pain of a right side and right lower extremity pain. A neurological examination demonstrated no motor weakness and no sensory loss of trunk and both lower limbs. Deep tendon reflexes were normal and Babinski signs were negative bilaterally. The right buttock and lower extremity pain was the only initial and major symptom of him. Magnetic resonance（MR） images revealed the presence of a dumbbell-shaped spinal tumor at the left Th9 level. MR image studies for brain, pelvic, and lumbar spine showed no other lesion. We considered that his symptom was caused by the compression of the left spinothalamic tract at thoracic spine level by the spinal tumor. The symptom disappeared immediately after the excision of the spinal tumor. Our experience suggests that thoracic cord compression caused by such as a dumbbell-shaped spinal tumor should be suspected in patients with buttock and lower extremity pain. And the symptom can occur at the contralateral side of the lesion.

Here, we report a case of spinal tuberculosis without elevation of C-reactive protein (CRP) at the initial visit mimicking spinal metastasis. A 70-year-old woman developed progressive paraplegia without a history of injury and came to our hospital for evaluation. Severe compression to the spinal cord with osteolytic destruction of the spinal vertebrae at T6-7 was observed without elevation of CRP. A T4-9 posterior decompression and fusion were performed. Although the pathology revealed no malignant tumor cells, a positron emission tomography-computed tomography (PET-CT) showed upregulation of the thyroid gland and aspiration cytology revealed a thyroid carcinoma. Thus, we diagnosed her with spinal metastases from thyroid carcinoma. Conservative treatment was chosen with the hope of a significant neurologic recovery; however, 9 months after the primary surgery, she returned to our hospital with reprogressive paraplegia. In addition to progression of osteolytic changes to the T5-7 vertebrae, a coin lesion on the right side of the lung and elevation of CRP were observed. Finally, we diagnosed her with spinal tuberculosis based on the results of a CT-guided needle culture. Two-stage surgeries (posterior and anterior) were performed in addition to administering antituberculosis medications. At the 1-year postoperative follow-up evaluation, both neurologic function and laboratory data were improved with T5-9 complete fusion. It is difficult to determine based on imaging findings alone whether osteolytic vertebrae represent spinal metastases or tuberculosis. Even though inflammatory biomarkers, such as CRP, were not elevated, we should consider the possibility of not only spinal metastases but also tuberculosis when planning surgery involving osteolytic vertebrae. In addition, the combination of neurological, imaging, and pathological findings is important for the diagnosis of spinal tuberculosis.

Background Recent reports indicate that oxidative stress induced by reactive oxygen species is associated with the pathobiology of neurodegenerative disorders that involve neuronal cell apoptosis. Here we conducted a cross-sectional study to evaluate serum levels of oxidative stress in cervical compression myelopathy. Methods Thirty-six serum samples were collected preoperatively from patients treated for acutely worsening compression myelopathy (AM) and chronic compression myelopathy (CM). Serum levels of oxidative stress markers were evaluated by measuring derivatives of reactive oxygen metabolites (ROM), which reflect concentrations of hydroperoxides. ROM in healthy individuals range from 250 to 300 (U. CARR), whereas ROM >340-400 and > 400 define moderate and severe levels of oxidative stress, respectively. Difference of ROM by the cause of disorders whether cervical spondylotic myelopathy (CSM) or cervical ossification of longitudinal ligament (OPLL), correlations between ROM and patient age, body mass index (BMI), history of smoking, existence of diabetes were examined. Neurological evaluations according to Japanese Orthopaedic Association (JOA) scores were performed and correlated with ROM. Results ROM increased to 349.5 +/- 54.8, representing a moderate oxidative stress, in CM samples. ROM increased to 409.2 +/- 77.9 in AM samples, reflecting severe oxidative stress which were significantly higher than for CM samples (p < 0.05). There was no significant difference by the cause of disorders (CSM or OPLL). ROM were significantly increased in AM serum samples from female patients versus AM male and CM patients (p < 0.05). There were no correlations between ROM and age, BMI, history of smoking, and existence of diabetes. A negative correlation between ROM and recovery rate of JOA score (R-2 = 0.454, p = 0.047) was observed in the AM group. Conclusions Although moderate oxidative stress was present in patients with CM, levels of oxidative stress increased in severity in patients with AM. These results suggest that postsurgical neurological recovery is influenced by severe oxidative stress in AM.

Background: A consensus on the optimal surgical procedure for thoracolumbar OVF has yet to be reached due to the previous relatively small number of case series. The study was conducted to investigate surgical outcomes for osteoporotic vertebral fracture (OVF) in the thoracolumbar spine.Methods: In total, 315 OVF patients (mean age, 74 years; 68 men and 247 women) with neurological symptoms who underwent spinal fusion with a minimum 2-year follow-up were included. The patients were divided into 5 groups by procedure: anterior spinal fusion alone (ASF group, n = 19), anterior/ posterior combined fusion (APSF group, n = 27), posterior spinal fusion alone (PSF group, n = 40), PSF with 3-column osteotomy (3CO group, n = 92), and PSF with vertebroplasty (VP + PSF group, n = 137).Results: Mean operation time was longer in the APSF group (p < 0.05), and intraoperative blood loss was lower in the VP + PSF group (p < 0.05). The amount of local kyphosis correction was greater in the APSF and 3CO groups (p < 0.05). Clinical outcomes were approximately equivalent among all groups.Conclusion: All 5 procedures resulted in acceptable neurological outcomes and functional improvement in walking ability. Moreover, they were similar with regard to complication rates, prevalence of mechanical failure related to the instrumentation, and subsequent vertebral fracture. Individual surgical techniques can be adapted to suit patient condition or severity of OVF. (c) 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

＜文献概要＞はじめに 近年のがん患者数の増加により,腫瘍専門医だけでなく一般整形外科医もがん患者を診療する機会や,がん患者の骨転移診療にたずさわる機会が増加している.本稿では,当科で2016年より開始した骨転移専門外来の診療データをもとに,骨転移集学的治療における整形外科へのニーズと役割について考察した.

We report the case of an incisional hernia through the wound made for iliac bone harvest for re-operative cervical fusion surgery. A 50-year old woman underwent revision anterior cervical discectomy and fusion (ACDF) using a poly ether ether ketone cage and titanium alloy locking plate for adjacent segment disease after prior ACDF. As an autograft, iliac cancellous bone was again harvested from the left iliac crest, using the prior surgical scar. Although only cancellous bone from the medial side of the iliac bone was collected, leaving the iliac crest intact, she complained of a protrusion from the left lower abdomen, of which diagnosis was an incisional hernia through the iliac bone harvest site. Formation of an incisional hernia at the iliac bone harvest site is a possible complication after spine surgery. Care must be taken for oblique abdominal muscle repair around the iliac bone harvest site, particularly in re-operative cases.

© The Author(s) 2019. Background: Dural tear and cerebrospinal fluid (CSF) leakage is known to be a complication of anterior thoracic spine surgery. If dural tear occurs on the ventral side of dura in combination with a pleural injury, it potentially becomes a subarachnoid-pleural fistula. The pressure gradient permits continuous flow of CSF from the subarachnoid space into the cavum thorax, resulting in an intractable subarachnoid-pleural fistula. We report two cases of successfully treated subarachnoid-pleural fistula using noninvasive positive-pressure ventilation (NPPV). Methods: Two patients, a 52-year-old man and a 54-year-old woman, underwent anterior thoracic spine surgery to treat thoracic myelopathy caused by spinal tumor and ossification of the posterior longitudinal ligament. During surgery, dural tear and CSF leakage to the cavum thorax due to perforation of the dura was observed. We treated with polyglycolic acid sheet (Neovel®) in combination with fibrin glue; a suction drainage tube was placed at the subfascial level and the wound was drained with negative pressure. However, after removal of the drainage tube, subarachnoid-pleural fistula was proven. We applied NPPV to the patients. Results: We used the application of NPPV for 2 weeks in the first patient and 1 week in the second patient. In both of them, subarachnoid-pleural fistula was attenuated without apparent adverse events. Conclusion: NPPV is noninvasive and potentially useful therapy to attenuate subarachnoid-pleural fistula after thoracic spinal surgery.

腰痛は混合性疼痛の要素を含むが,下肢・臀部痛を呈する場合は神経障害性の可能性が高い。超高齢社会に突入した現代では加えて骨や筋由来の疼痛も着目されつつあり,たとえば骨粗鬆症では骨折等がなくとも病態そのものが惹起する慢性の疼痛発生機序がある。また骨粗鬆症との合併率が高いサルコペニアもADL障害・疼痛をきたしうる。また,腰痛患者の活動データを蓄積・解析した結果,特に急性期での睡眠障害が優位であることが示唆されるなど,運動器慢性疼痛の機序とその評価に対するアプローチは多面化している。(著者抄録)

The aim of this study was to elucidate the bone regeneration-inducing capability of Affinos®, a newly developed, high-porosity unidirectional porous β-TCP artificial bone. We compared the ability of Affinos® and OSferion®, a commercially available β-TCP product, to induce bone regeneration following implantation into bony defects left after fibula harvesting for spinal fusion surgery. Study subjects underwent surgery to harvest non-vascularized fibula grafts for spinal fusion surgery and were implanted with either Affinos® (19 patients) or OSferion® (15 patients, control group) at the defect site. The minimal and mean follow up periods were 6 and 11 months after surgery, respectively. X-rays of the lower leg taken 1-2 weeks after surgery and at the final follow-up visit were used to evaluate fibular-β-TCP continuity and fibula defect filling ratio. There was no significant difference in radiographic continuity in the fibula between the two groups. The fibula defect filling ratio for the Affinos® group decreased from 0.94 ± 0.17 at 1-2 weeks to 0.77 ± 0.14 at 10 months. For the OSferion® control group, the fibula defect filling ratio decreased from 0.94 ± 0.14 at 1-2 weeks to 0.52 ± 0.27 at final follow-up. The Affinos® group showed a significantly higher fibula defect filling ratio compared to that for the OSferion® group (p = 0.003). These results indicate that Affinos® has slow absorption rates and significant defect filling activity compared with OSferion®. Thus, Affinos® could be a suitable substitute to fill bony defects induced by fibula harvesting for spinal reconstruction surgery.

BACKGROUND: Intradural extramedullary spinal metastasis is a relatively rare condition. Furthermore, there are few reports with the initial presentation being a neurological symptom from an intradural metastasis. We report a case of a patient with metastasis to the cauda equina from breast cancer found due to neurological symptoms as the initial presentation. CASE PRESENTATION: A 76-year-old Japanese woman who was previously healthy presented to our hospital with bilateral severe buttock and lower extremity pain without any history of injury. A solitary intradural cauda equina mass was found by magnetic resonance imaging at the L2/3 level, and we suspected a schwannoma initially. The patient hoped to undergo surgery due to the severe pain. However, the chest computed tomographic scan obtained to assess the patient's general status showed the suspected breast cancer of the left side and a lung metastasis. Hence, we considered the possibility of cauda equina tumor metastatic from the breast cancer. We performed an L1-3 laminectomy and tumor extirpation. The pathology revealed adenocarcinoma. After surgery, she had relief from pain, and her status remained satisfactory until she died 9 months after surgery. CONCLUSIONS: It is difficult to clarify whether the cauda equina tumor is benign or malignant based only on Magnetic resonance imaging findings. Clinicians should consider the possibility of metastasis when planning the surgery for intradural cauda equina tumor extirpation.

PURPOSE: We investigated the involvement of sarcopenia in middle-aged and elderly women with degenerative lumbar scoliosis (DLS). METHODS: A total of 971 women (mean age 70.4 years) were included in our study. These included 87 cases of DLS (mean 73.8 years) and 884 controls (69.8). Lumbar and femur BMD was measured for all participants using dual-energy X-ray absorptiometry. We used a bioelectrical impedance analyzer to analyze body composition, including appendicular skeletal muscle mass index (SMI; appendicular lean mass (kg)/(height (m))2. We determined bone density and skeletal muscle mass in both groups and determined the prevalence of sarcopenia. We examined the correlation between bone density and appendicular muscle mass in both groups. We also examined factors related to scoliosis using logistic regression analysis. RESULTS: The DLS group showed significantly higher lumbar BMD, lower femur BMD, lower lean mass arm, and lower lean mass leg, and lower lean mass trunk (p < 0.05). Sarcopenia prevalence (SMI < 5.75) was 59.8% in DLS subjects and 42.8% in controls, revealing a high prevalence in DLS (p < 0.05). In both groups, lumbar and femur BMD were positively correlated with appendicular muscle mass. By logistic regression analysis, trunk muscle mass was detected as a risk factor for DLS independent of age (p < 0.05). CONCLUSIONS: In middle-aged and elderly women, prevalence of sarcopenia was 59.8% in DLS cases and 42.8% in controls, which revealed a high prevalence in DLS. A decrease in trunk muscle was a significant risk factor for DLS that was independent of age. These slides can be retrieved under Electronic Supplementary Material.

近年では超高齢社会を背景に、骨粗鬆症に起因する脆弱性骨折に対する手術が多く実施されるようになってきている。そこで本稿では、脆弱性骨折手術後の骨粗鬆症薬物療法について、1)骨癒合促進、2)二次骨折予防の2つの観点から概説する。(著者抄録)

新鮮脆弱性椎体骨折に対しweekly PTH製剤(テリボン56.5μg、週1回皮下注射)を投与した50例を対象に、投与前から投与後10週に日本整形外科学会腰痛評価質問票(JOABPEQ)を患者本人が毎週回答を記載した。得られたデータを集計し、疼痛改善の指標として疼痛関連障害スコア、ADL改善の指標として社会生活障害スコアの変化を調査した。その結果、疼痛関連障害スコアは投与前と比較して経時的に増加し、投与後6週以降に投与前と比較し20ポイント以上の上昇を認めた。また、社会生活障害スコアも投与前と比較して経時的に増加し、投与後8週以降に20ポイント以上の上昇を認めた。新鮮脆弱性椎体骨折はweekly PTH製剤投与により疼痛は6週、ADLは8週で改善すると考えられた。

Study design: A multicenter cross-sectional study. Objectives: To clarify the relationship of trunk muscle mass with low back pain, spinal sagittal balance, and quality of life. Summary of background data: Few reports have investigated the relationship of trunk muscle mass with lumbar spine function and spinal balance, and the clinical significance of trunk muscle mass remains unclear. Methods: Patients attending spinal outpatient clinics at 10 different medical institutions were enrolled in this study. Patient demographics, trunk muscle mass and appendicular skeletal muscle mass (ASM) measured by bioelectrical impedance analysis (BIA), body mass index (BMI), Charlson Comorbidity Index (CCI), the Oswestry Disability Index (ODI), visual analog scale (VAS) for low back pain, sagittal vertical axis (SVA), and EuroQol 5 Dimension (EQ5D) score were investigated. Multivariate nonlinear regression analysis was used to investigate the association of trunk muscle mass with the ODI, VAS score, SVA, and EQ5D score. Results: Of 2551 eligible patients, 1738 (mean age 70.2 ± 11.0 years; 781 men and 957 women) were enrolled. Trunk muscle mass was significantly correlated with the ODI, VAS score, SVA, and EQ5D score (P < 0.001) when adjusted for age, sex, BMI, ASM, CCI, and history of lumbar surgery. Patient deterioration was associated with a decrease in trunk muscle mass, and the deterioration accelerated from approximately 23 kg. Conclusions: Trunk muscle mass was significantly associated with the ODI, VAS score, SVA, and EQ5D score. Trunk muscle mass may assume an important role to elucidate and treat lumbar spinal dysfunction and spinal imbalance. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.].

プレガバリンは電位依存性カルシウムチャネルのα2δサブユニットと結合し、興奮性神経伝達物質の遊離を抑制して鎮痛効果をもたらす。本邦では末梢性・中枢性神経障害性疼痛や線維筋痛症に伴う疼痛、帯状疱疹後神経痛、糖尿病性神経障害に伴う痛みやしびれ、脊髄損傷後疼痛などに対して有意な鎮痛効果が示されている。一方でめまいや鎮静、傾眠などの副作用が知られており、最小用量から開始し漸増するなどの処方の工夫によりその発生が抑制されうる。腎機能低下症例、透析症例では慎重投与を心がけることが重要である。神経障害性疼痛に加え侵害受容性疼痛や心理社会的要因など多因子由来の病態である慢性の腰下肢痛に対しては必ずしも全例で効果を示すわけではないが、この場合NSAIDsなどの併用処方が有用である。本剤処方において最も重要なのは入念な診察に基づく確実な神経障害性疼痛の診断であり、臀部痛・下肢痛症例における神経障害性疼痛の関与の報告はその根拠のひとつとなる。(著者抄録)

BACKGROUND: Giant cell tumor is known to be a benign neoplasm that arises most commonly in the long bones, while cases in the spine are rare. Recently, denosumab, a monoclonal antibody that inhibits receptor activator of nuclear factor-kappa β ligand, has been used to treat patients with giant cell tumor. However, there are few reports of total en bloc spondylectomy being used for paravertebral giant cell tumor lesions following denosumab therapy. CASE PRESENTATION: Our patient was a 20-year-old Japanese woman with a 4-month history of lower back pain. A spinal computed tomography scan and magnetic resonance imaging of her lumbar spine revealed an osteolytic lesion involving the L3 vertebral body, and the tumor extended toward the left side of the paravertebral soft tissue and into the left pedicle. The lesion was diagnosed as a giant cell tumor by needle biopsy. Denosumab treatment calcified the paravertebral giant cell tumor lesion and the tumor vertebral body was removed completely by total en bloc spondylectomy. CONCLUSION: This case report describes a patient with a paravertebral giant cell tumor who was successfully treated by preoperative denosumab injection followed by total en bloc spondylectomy.

脊髄刺激療法は難治性腰痛患者の痛みを軽減し、歩行機能を中心とした患者のADL改善につながる治療法である。自験例ではオピオイド等の鎮痛薬減量により患者の身体的負担の軽減や医療経済の改善にも有効な手段であった。近年、デバイス改良によりMRI対応可能となり、さらには自動刺激調整機能が備わった。適応疾患および病態を見極め、心理的サポート等包括的な医療を行うことで更なる効果が期待できる。今後、高齢化社会に伴いさらに増加すると予想される難治性疼痛患者に対する選択肢となり得る治療法である。(著者抄録)